Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial
Authors: David J Beard, Loretta Davies, Jonathan A Cook, Jamie Stokes, Jose Leal, Heidi Fletcher, Simon Abram, Katie Chegwin, Akiko Greshon, William Jackson, Nicholas Bottomley, Matt Dodd, Henry Bourke, Beverly A Shirkey, Arsenio Paez, Sarah E Lamb, Karen Barker, Michael Phillips, Mark Brown, Vanessa Lythe, Burhan Mirza, Andrew Carr, Paul Monk, Carlos Morgado Areia, Sean O'Leary, Fares Haddad, Chris Wilson, Andrew Price, Richard Emsley, George Peat, Martyn Snow, Marion Campbell, Tessa Howell, Hilary Johnson, Stephen McDonnell, Thomas Pinkney, Mark Williams, Helen Campbell, Jackie Davies, Jiyang Li, Christina Bagg, Laura Haywood, Anne Nicholson, Joanne Riches, Sean Symons, Mark Vertue, Louay Al Mouazzen, Rachel Bray, Damian Clark, James Coulthard, Tim Holland, Nick Howells, Andrew Jones, Richard Kapur, Alastair Kiszely, Harry Krishnan, Karen MacDonald-Taylor, Jon Manara, James Murray, Corina Negrut, Vishai Pai, Andrew Porteous, Sven Putnis, James Robinson, Shav Rupasinghe, Veenesh Selvaratnam, James Smith, Nick Smith, Jarrad Stevens, Clare Taylor, Anthony Theodorides, Niraj Vetharajan, Helen Vint, Lucy Young, Susan Bullock, Rebecca Cook, Alexander Dodds, Amanda Freeman-Hicks, Paula Hillout, Thomas Cornell, Abbie Coutts, Suzy Dean, Nicki Devooght-Johnson, Emma Ferrell, Eve Fletcher, Chrissie Hall, Benjamin Kent, Sandra Kessly, Robin Kincaid, Mohamed Lazizi, Ahmed Mostafa, Toby Nisbett, Tim Powell, Peter Riddlestone, Andrew Roberton, Jessica Summers, Lucy Whitbread, Belinda Wroath, Emma Fenlon, Andrew Hall, Helen Jeffrey, Raghuram Thonse, Debra Dunne, Andy Metcalfe, Kerri McGowan, Simon Middleton, Feisal Shah, Tim Spalding, Charlie Marie Suddens, Tamar Sweed, Joanna Teuke, Peter Thompson, David Wright, Justine Amero, Emma Brown, Hugh Chissell, Andrea Croucher, Gareth Dickinson, Catherine Hawkes-Blackburn, Alice Peacocke, Graham Smith, Carol Snipe, Kim Dearnley, Reza Mayahi, Barry Andrews, Massimo Barcelona, Hazel Giles, Abdulkerim Gokturk, Paul Harnett, Katie Jeeves, Joyce Kadunyi, Sheena Mendoza, Ines Reichert, Marta Santamaria, Harshinder Virdee, Sanjeev Anand, Nayef Aslam-Pervez, Stephen Draycott, Faye Howarth, Irfan Jina, Niall Maher, Denise Ross, Lindsey Worstenholme, Abdul Baig, Arun Bhaskaran, Daniel Banks, Tracy Brear, Carla Christie, Laura Cowen, Jack Davis, Ross Dixey, Colin Esler, Amirah Essop-Adam, Christina Haines, Linzy Houchen-Wolloff, Husein Varachia, Richard Wood, Glaxy Gray, Jessica Nichols, Alice Panes, Susan Partridge, Lawrie Rogerson, Pankaj Sharma, David Triggs, Ian Venables, Danielle Wilcock, Sarah Buckley, Thelma Darian, Elizabeth Denis, Jo Duncan, Charlotte Hirst, James Newman, Fern Richardson, Jon Smith, Megan Adcode, Megan Cottingham, Eliza Foster, Andrew Kelly, Niamh McKay, Jane Rewbury, Alison Whitcher, James Williams, Esther Zebracki, Llinos Davies, Jayadeep Jayachandran, Alison Tardivel, Victoria Whitehead, Martha Batting, Amy Bond, Marc Deakin, Christopher Dodd, Alison Hudak, Samantha Hynes, Luke Jones, Gail Lang, David McKenna, Susan Morris, Clare Scott-Dempster, Adam Sykes, Iason Vichos, Simon Wood, Rupert Clifton, Stephanie Diaz, Craig Hendy, Nishil Modi, Brendan O'Mahony, Susan O'Sullivan, Nicola Parker, Mira Pecheva, Rowan Rumonovic, Emma McLoughlin, Jeremy Rushbrook, Anna Thornhill, Valerie Parkinson, Rafael Sales, Katja Van De Snepscheut-Jones, David Wilcock, Daniel Wright, Joanna Allison, Simon Baker, Kate Beesley, Gill Ferrari, Benedict Lankester, Alison Lewis, Joanne Lyons, Jamie O'Callaghan, Sarah Sutcliffe, Dianne Wood, Emily Bannister, Chloe Brown, Debbie Burden, Terence Campbell, Emma Craig, Rashmi Easow, Julie Foxton, Alexandra Hazlerigg, Chethan Jayabev, Rosie Murdoch, Georgie Parsons, Harry Brown, Paula Carvelli, Rugaia Montaser, Ali Pepper, Sinduja Sivarajan, Oliver Templeton-Ward, Eva Wilson, Julie Cronin, Sarah Diment, Victoria King, Katharine Shean, Leonidas Vachtsevanos, Katharine Wilcocks, Ben Wilson, Paul McNestry, Joanna Ollerenshaw, James Stoddard, Paul Sutton, Sanjay Anand, Judith Bell, Albert Chikate, Diane Daniel, Timothy Davies, Tom Finnigan, Antonio Frasquet-Garcia, Susan Hopkins, Sharon Kerrison, Angela McGowan, David Sands Johnson, Lara Smith, Philip Turner, Helen Wilkinson, Lynne Allsop, Deborah Anthony, Rebecca Boulton, Sarah Brown, Vikram Desai, Mandy Gill, Cheryl Heeley, Sushrut Kulkarni, Wayne Lovegrove, Dominic Nash, Terri Ann Sewell, Sarah Shelton, Katie Slack, James Cartwright, Lynda Connor, Andrew Davies, Caroline Davies, Glyn Gainard, Dave Graham-Woollard, Carl Murphy, Leanne Quinn, Caradog Thomas, Jenny Travers, Marie Williams, Amanda Bell, Sunny Deo, Katharine Francis, Tracy Jackson, Laura McCafferty, Basalingappa Navadgi, Karan Plank, Venkat Satish, Claire Thelwall, Rachel Knight, Rahul Patel, Bruce Paton, Ashutosh Acharya, Utuman Aland, Miltiades Areirobulos, Pascal de Feyter, Lisa Ditchfield, Hafiz Iqbaz, Daniel Massey, Gareth Stables, Sarah Appleby, Michael Brown, Sarah Cable, Alexander Damen, Joana Da Rocha, Louise Foster, Elizabeth Hamilton, Catriona Hatton, Cassie Honeywell, Kunal Kulkarni, Lucy Markham, Haadiya Mohammed, John O'Grady, Yogesh Joshi, Heather Mclintock, Tania Morgan, Jane Stockport, Victoria Whitehead, Pranshu Agrawal, Jo Armstrong, Shannon Briggs, Ben Coupe, Anne Evans, Rob Gilbert, Sandra Latham, Aslam Mohammed
Journal: The Lancet (2022)

Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management.The UK National Institute for Health Research Health Technology Assessment Programme.